Financial Hardship Program

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Footprints to Recovery’s Financial Hardship Program is designed to reduce patient costs for eligible patients with limited financial means. Footprints to Recovery offers the Financial Hardship Program to individuals who are unable to pay in full for services.

The company will not discriminate on the basis of ethnic group identification, religion, age, sex, color, gender, race, sexual orientation, or disability. Company’s sliding scale fee schedule is based on the Federal Poverty Guidelines.

To be considered for the Financial Hardship Program please fill out the below application in full. Upon receiving your application Footprints to Recovery’s financial specialists will review your information and contact you with further steps.

If you have any questions along the way, feel free to contact us

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Financial Hardship Program Application

Please complete the following information to help us determine if you or members of your family are eligible for a percentage cost reduction. The percentage cost reduction will apply to all services received at this facility, but not to those services received outside the facility. This form must be completed every 12 months or if your financial situation changes.

Patient
Patient's Name (First/Last)*
Facility Location*
Account Number (If Applicable)
Head of Household
Head of Household Name (First/Last)*
Email*
Invoice Number (If Applicable)
Street*
City*
State*
Zip Code*
Phone*
Please list self, spouse and dependents under age 18.
Relationship*
First Name*
Last Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Relationship
First Name
Last Name
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship
First Name
Last Name
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship
First Name
Last Name
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship
First Name
Last Name
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship
First Name
Last Name
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship
First Name
Last Name
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship
First Name
Last Name
Date of Birth
Date Format: MM slash DD slash YYYY
Total Household Size (Number of Individuals Living in House)
Total*
Annual Household Income
Gross wages, salaries, tips, etc.
Self*
Spouse*
Other*
Total Gross, Etc.*
Income from business, self-employment, and dependents
Self*
Spouse*
Other*
Total Business, Etc.*
Interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources
Self*
Spouse*
Other*
Total Interest, Etc.*
Unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income
Self*
Spouse*
Other*
Total Unemployment, Etc.*
Total Income
Self*
Spouse*
Other*
Final Total*
NOTE: Please include copies of tax returns, W2s, pay stubs, or any other information verifying income.
Please provide any additional notes on your circumstances:
File
Drop files here or
Type Your Name to Sign
First Name*
Last Name*
*
- I certify that the family size and income information shown above is correct.
Email
This field is for validation purposes and should be left unchanged.

Insurance

Your insurance may cover a portion or the bulk of treatment costs, which vary from person to person and depend on your specific policy. Footprints to Recovery accepts most major insurances and will work directly with your provider to get you the best coverage.

Verify Insurance Coverage »

Private Pay

For those who would rather not use their insurance or are only approved for coverage of a portion of treatment, we accept private pay at any of our facilities.

We offer flexible payment plan options if needed.

Financing

No insurance? Can’t do private pay? We have formed relationships with Prosper Healthcare, who offers special loan packages that are affordable and tailored to the cost of treatment. Through Prosper Healthcare you can apply for full or partial financing.

Prosper Healthcare »

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Financial Hardship Program Application

Patient

Head of Household

Please list self, spouse and dependents under age 18.

Total Household Size (Number of Individuals Living in House)

Annual Household Income

Gross wages, salaries, tips, etc.

Income from business, self-employment, and dependents

Interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources

Unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income

Total Income

Type Your Name to Sign

Insurance

Private Pay

Financing

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